An Approach to Care Management - By Dr. Singh

May 12, 2017

Case Study: Your patient comes in for his scheduled visit. The exam is unremarkable and he reports he’s doing quite well. Then, right before he leaves, he insists that you give him an approval for an electric scooter so that he can shop more easily in Walmart. He explained that his neighbor has one and he thinks he should have one too. From the list below, what should you do?

Tell him it is not covered, period.

Agree immediately and write a prescription for a scooter and ask what color he would like?

Get into an argument with the patient why you don’t think it is covered by Medicare, why he should not bother asking again, and refuse to send in a request.

Do a thorough review his current status including a comprehensive review of his functional limitations including ADLs. If there were no changes, explain that while you are not an insurance expert, given his unremarkable exam, it does not appear that it may be covered, but you will be happy to send in his request to his insurance company who will review and make a determination.

Discussion:

It is important to understand what a National or Local Covered Determination (NCD/LCD) is. Medicare provides a National Coverage Database website that provides guidance on many items and services covered and/or covered if certain specific criteria are met.

Always remember, members have the right to request anything and they are not expected to know the intricacies of what is covered or non-covered.

We should never put ourselves in a position where we deny any requests from members. Members have a right to be heard, and their requests should be acted upon. Only the Health Plan can make a preservice denial decision and there are extensive rights the member has through 5 different levels of appeal and the Medicare beneficiary is entitled to have the reason why their request has been denied in plain, understandable language, not medical-speak.

We are responsible for documenting the medical condition and what the patient is requesting.

In instances when the patient’s request is not part of your treatment plan, or, you just aren’t sure it is a covered benefit under Medicare, like the scooter, then most certainly, you have to right to ask the plan to review and make a determination for the member.

Our IPA has resources to help you. Our Care Management nurses will research your questions. They review all the available medical records as well as do a thorough search on the National Coverage Database in an effort to provide you with the information you need to approve the request. If they can’t find a reason to approve, they will provide you with some of the requirements needed for the request to be covered and communicate it to you. For example, a failure of conservative management before an invasive procedure, etc.

With regard to scooters, providers must document the functional status of the patient, e.g., if he is ambulating and how much. Scooters are not meant for shopping in retail centers.

Please do NOT write a prescription for the electric scooter or at least add to the script, if you feel it should be written, “Patient requesting scooter”? The signed prescription by the PCP can be interpreted as PCP agreeing to the item/service/referral and the plan may not be able to deny the same even if the request seems as not meeting medical necessity

One does not have to agree with the patient’s request or disagree on the progress note. Just document clearly what his medical condition is and the nature of his request.

Since this patient is absolutely insisting for the desired piece of equipment, it does not help to get into an argument or in a position where one is making the decision about the need for the product.

Denials can only be made by insurance plans. We are providers and should send such requests to the plan for medical determination if we don’t think the request is a covered benefit. Similar requests, such as spas, elevators for one’s homes, out of network referrals, etc., should be addressed in similar manner.